Retrograde crossing and snaring technique to retain access after lead extraction in the setting of venous stenosis: Another tool in the toolbox

Figure 1. A: During extraction, the tip of the lead (red arrow) is pulled back to the innominate vein, not allowing further advancement of the extraction sheath (orange arrows). B: Left-sided upper-extremity peripheral venogram showing lack of opacification of the innominate vein, with the yellow dotted line indicating outline of the axillary/subclavian vein. The white asterisk and bracket indicate the zone where the wire could be advanced beyond the sheath despite absence of contrast flow (likely area of dense fibrosis without complete stenosis) and the red bar indicates the zone where the wire could not be advanced antegrade despite multiple strategies and attempts (likely area of complete stenosis). Venous collaterals are seen across the chest wall (orange arrows).

Figure 2. A: Retrograde crossing of the site of stenosis with a Glidewire Advantage (Terumo, Tokyo, Japan; wire tip indicated by red arrows). B: Tip of the wire (red arrows) extending beyond the multipurpose catheter (blue arrow), and snared with the help of a multiloop snare (orange arrow) advanced through the extraction sheath. C: Wire (red arrows) pulled out of the extraction sheath for through-and-through access.

Figure 3. A: Long sheath (red arrows) advanced over the Glidewire Advantage (Terumo, Tokyo, Japan) beyond the site of stenosis. B: Postprocedure chest radiograph demonstrating biventricular implantable cardioverter-defibrillator implant.